| NPI | 1205548591 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: TX PA18938) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: IL 085-009979) |
| Enumeration Date | 2022-12-19 |
| Last Update Date | 2025-10-14 |